Health Insurance Chapter 5:Legal And Regulatory Insurance

1. A patients spouse comes to the office and request diagnostic and treatment information about his wife. The spouse is the primary policy holder on which his wife is named on the policy as a dependent. The insurance specialist should

Allow the patients spouse to review the actual record in the office but not release a copy

Inform the patients spouse that he must request the information from the insurance company

Obtain a signed patient authorization from the wife before releasing patient information

Release a copy of the information to the patients spouse because he is the primary policy holder

The correct answer is to obtain a signed patient authorization from the wife before releasing patient information. This is because patient privacy and confidentiality are important in healthcare, and releasing patient information without proper authorization would violate these principles. The spouse may be the primary policy holder, but this does not automatically grant them access to the patient's medical information. The patient's consent is necessary to ensure that their privacy rights are respected.

Explanation

The correct answer is to obtain a signed patient authorization from the wife before releasing patient information. This is because patient privacy and confidentiality are important in healthcare, and releasing patient information without proper authorization would violate these principles. The spouse may be the primary policy holder, but this does not automatically grant them access to the patient's medical information. The patient's consent is necessary to ensure that their privacy rights are respected.

2. An attorney calls a physicians office and requests that a copy of his clients medical record be immediately faxed to the attorneys office. The insurance specialist should?

Call the HIPPA hot line number to report a breach of confidentiality

Explain to the attorney that the office does not fax or copy patients records

Instruct the attorney to obtain the patients signed authorization

Retrieve the patients medical record and fax it to the attorney

The insurance specialist should instruct the attorney to obtain the patient's signed authorization because sharing a patient's medical record without their consent is a violation of HIPAA regulations. The specialist should prioritize patient confidentiality and ensure that proper procedures are followed before releasing any medical information.

Explanation

The insurance specialist should instruct the attorney to obtain the patient's signed authorization because sharing a patient's medical record without their consent is a violation of HIPAA regulations. The specialist should prioritize patient confidentiality and ensure that proper procedures are followed before releasing any medical information.

3. The physician submitted a claim on which he had accepted assignment-of-benifits statement for the office. The payer determined that reasonable charge for services provided to the patient was $500 and reimbursed the physician $400. The patient paid $200 at the time services were provided. (The payer required the patient to pay a 20% coinsurance amount when services were provided.) The insurance specialist should

Charge the patient an additional $100

Refund the patient a $100 overpayment

Return the $400 check to the payer

Submit the patients name to collections

The physician submitted a claim for $500, but the payer determined that the reasonable charge for the services provided was only $400. The payer reimbursed the physician $400 and the patient paid $200 at the time of service, which was the required 20% coinsurance. This means that the patient overpaid by $100 ($200 - $100). Therefore, the insurance specialist should refund the patient the $100 overpayment.

Explanation

The physician submitted a claim for $500, but the payer determined that the reasonable charge for the services provided was only $400. The payer reimbursed the physician $400 and the patient paid $200 at the time of service, which was the required 20% coinsurance. This means that the patient overpaid by $100 ($200 - $100). Therefore, the insurance specialist should refund the patient the $100 overpayment.

4. Which is considered Medicare fraud?

Billing for services that were not furnished and misrepresenting diagnosis to justify payment

Charging excessive fees for services, equipment, or supplies provided by the physician

Submitting claims for services that are not medically necessary to treat a patients condition

Violating participating provider agreements with the insurance companies and government programs

Medicare fraud refers to intentionally billing for services that were not actually provided and misrepresenting the diagnosis to justify receiving payment. This involves deceitfully claiming reimbursement for services that were not rendered, which is a fraudulent practice. This type of fraud can result in financial losses for the Medicare program and can also harm patients by subjecting them to unnecessary medical procedures or treatments.

Explanation

Medicare fraud refers to intentionally billing for services that were not actually provided and misrepresenting the diagnosis to justify receiving payment. This involves deceitfully claiming reimbursement for services that were not rendered, which is a fraudulent practice. This type of fraud can result in financial losses for the Medicare program and can also harm patients by subjecting them to unnecessary medical procedures or treatments.

5. A commercial insurance company sends a letter to the physician requesting a copy of a patients entire medical record in order to process a payment. No other documents accompany the letter. The insurance specialist should?

Contact the patient via telephone to alert him about the request

Let the patients physician handle the situation personally

Make a copy of the record and mail it to the insurance company

Require a signed patient authorization letter from the insurance company

The correct answer is to require a signed patient authorization letter from the insurance company. This is because the insurance company is requesting a copy of the patient's medical record, which contains sensitive and confidential information. Requiring a signed authorization letter ensures that the patient has given their consent for the release of their medical records to the insurance company. This helps to protect the patient's privacy and comply with legal and ethical requirements. Contacting the patient or letting the physician handle the situation personally may not be necessary or appropriate in this case.

Explanation

The correct answer is to require a signed patient authorization letter from the insurance company. This is because the insurance company is requesting a copy of the patient's medical record, which contains sensitive and confidential information. Requiring a signed authorization letter ensures that the patient has given their consent for the release of their medical records to the insurance company. This helps to protect the patient's privacy and comply with legal and ethical requirements. Contacting the patient or letting the physician handle the situation personally may not be necessary or appropriate in this case.

6. A patient receives services on April 5, totaling $1,000. He paid a $90 coinsurance at the time services were rendered. (The payer required the patient to pay a 20% coinsurance at the time services were provided) The physician accepted assignment, and the insurance company established the reasonable charge as $450. On July 1 the provider received $360 from the insurance company. On August 1 the patient received a check from the insurance company in the amount of $450. The overpayment was__________, and the_____________must reimburse the insurance company.

$450, patient

$450, physician

$550, patient

$640, physician

The patient received a check from the insurance company in the amount of $450, which is the same as the reasonable charge established by the insurance company. Therefore, there was an overpayment of $450 made to the patient. The patient must reimburse the insurance company for this overpayment.

Explanation

The patient received a check from the insurance company in the amount of $450, which is the same as the reasonable charge established by the insurance company. Therefore, there was an overpayment of $450 made to the patient. The patient must reimburse the insurance company for this overpayment.

7. The patient underwent office surgery on October 10, and the third-party payer determined the reasonable charge to be $1,000. The patient paid 20% coinsurance at the time of the office surgery, The physician and patient each received a check for $500, and the patient signed the check over to the physician. The overpayment was__________, and the_________must reimburse the insurance company

$200, patient

$200, physician

$500, patient

$500, Physician

The overpayment was $200, and the physician must reimburse the insurance company. This is because the patient paid 20% coinsurance at the time of the office surgery, which amounted to $200. However, both the physician and the patient received a check for $500 each. Since the patient signed the check over to the physician, the physician received an additional $200 that was not owed to them. Therefore, the physician must reimburse the insurance company the overpayment of $200.

Explanation

The overpayment was $200, and the physician must reimburse the insurance company. This is because the patient paid 20% coinsurance at the time of the office surgery, which amounted to $200. However, both the physician and the patient received a check for $500 each. Since the patient signed the check over to the physician, the physician received an additional $200 that was not owed to them. Therefore, the physician must reimburse the insurance company the overpayment of $200.

8. Which is considered Medicare abuse?

Falsifying certificates of medical necessity, pans of treatment, and medical records to justify payments

Improper billing practices that result in Medicare payment when the claim is legal responsibility of another third-party payer

Soliciting, offering, or receiving a kickback for procedures and/or services provided to patients in the physicians office

Unbundling codes;that is, reporting multiple CPT codes on a claim to increase reimbursement from a payer

Medicare abuse refers to any practices that result in unnecessary costs to the Medicare program. Improper billing practices that result in Medicare payment when the claim is the legal responsibility of another third-party payer can lead to unnecessary payments from Medicare. This is considered Medicare abuse because it involves billing Medicare for services that should be covered by another payer, resulting in unnecessary costs for the Medicare program.

Explanation

Medicare abuse refers to any practices that result in unnecessary costs to the Medicare program. Improper billing practices that result in Medicare payment when the claim is the legal responsibility of another third-party payer can lead to unnecessary payments from Medicare. This is considered Medicare abuse because it involves billing Medicare for services that should be covered by another payer, resulting in unnecessary costs for the Medicare program.

9. An insurance company calls the office to request information about a claim. The insurance specialist confirms the patients dates of service and the patients negative HIV status. The insurance specialist

Appropriately released the dates of service but not the patients negative HIV status

Breached patient confidentiality by confirming the dates of service

Did not breach patient confidentiality because the patients HIV status was negative

Was in compliance with HIPPA provisions concerning release of dates of service and HIV status

The insurance specialist appropriately released the dates of service but not the patient's negative HIV status because sharing the dates of service is necessary for the insurance company to process the claim. However, disclosing the patient's HIV status would be a breach of patient confidentiality as it is sensitive medical information that should not be shared without the patient's consent. This action is in compliance with HIPAA provisions, which protect patient privacy and require healthcare providers to safeguard sensitive health information.

Explanation

The insurance specialist appropriately released the dates of service but not the patient's negative HIV status because sharing the dates of service is necessary for the insurance company to process the claim. However, disclosing the patient's HIV status would be a breach of patient confidentiality as it is sensitive medical information that should not be shared without the patient's consent. This action is in compliance with HIPAA provisions, which protect patient privacy and require healthcare providers to safeguard sensitive health information.

10. The 66 year old patient was treated in the emergency department (ED) for a fractured arm. The patient said, "I was moving a file cabinet for my boss when it tipped over and fell on my arm" The facility billed Medicare and received reimbursement of $550. The facility later determined that Medicare was not the payer because this was a workers compensation case.

Is guilty of both fraud and abuse according to HIPPA because of accepting the $550

Must give the $550 check to the patient, who should contact workers compensation

Should have billed the employers workers compensation payer for the ED visit

Was appropriately reimbursed $550 by medicare for the emergency department visit.

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Explanation

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